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WELL DE.3"TRUCTIC)IN PERMIT PUBLIC WATER SYSTEM ❑ Yeo SAtd JdPAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (2091953-7697 FOR INSPECTIONS EXPIRES '1 YEAR FROM DATE ISSUED JOB ADDRESS �� CITY21P_ ..LOZL % �� Received1 _ CROSS STREET S /G��ZAPN i U PARCEL SI7_ELL?tAND USE A PLICATION # OWNER.r_ /LL PHONE J y/L(n /� C: OWNER ADDRESS f L%p' CITY/STATE/ZIP CONTRACTOR agm�p=:F PHONE: 7 emitted CONTRACTOR ADDRESS CITY/STATE21P , Invoice # 6 C-57 WELL DRILLING LICENSE NUMBER p I� EXPIRATION DATE PERFORATION CONTRACTOR PHONE PERFORATION CONTRACTOR ADDRESS CITY/STATE/71P ❑ C-57 Well Drilling license Number Expiration Date ❑ Bureau of Alcohol, Tobacco and Firearms - Users of High Explosives License Number Expiration Date ❑ CHP Hazardous Material Transportation for Explosives License Number Expiration Date . ❑ San Joaquin County Sheriff -Coroner Explosives Application and Permit License Number Expiration Date _ ❑ California Occupational Safety Health - Blaster License Number Expiration Date REASON FOR DESTRUCTION ❑ Dry Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactive ❑ Test Hole Detected/Suspected Well Water Contaminant(s) Adjacent property with contamination (Address) Known Soil/Water contaminants at adjacent property__ EXISTING WELL CONSTRUCTION DETAILS * Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Log copy attached ❑ Yes ❑ No Grout Seal ❑ No ❑ Yes _- - It below ground surface (bgs) Hole Diameter _ _ inches Well Conductor Casing ❑ Y s ❑ No Depth of Conductor Casing It bys +_ Diameter of Conductor Casing ?P—ft inches Well Casing Diameter inches Total Depth _/_ t Depth to Water_ Depth of Casing .__--------- _ It bgs DESTRUCTIC"N SPECIFICATION Sealing Material from -_ _ ___ft bgs to _ _ .-_ ft bgs Filler Material _ from __ _ __ _ ft bgs to ____ __ ft bgs Well casing to be perforated by one of the following methods: _ -__ from It bgs toIt bgs El Mills Knife _ _Number of cuts every _ It arid/or ❑ Explosives ❑ Detonating cord ❑ with projectiles every It ❑ without projectile ❑ Detonating cord and boosters Elwith projectiles every _ _ It ❑ without projectile ❑ Other Sealing Material at Cement (94 Ib bag/5-6 gal water) Sand Cement _ sack rnix/7 gal water I Its Bentonite (70° > solids) Manufacturer Sp °% olids o Name Piacement Melliod Pumped ree FaU J . _-_ -. Specs on File Specs Su emitted Othei Seal Completion Complete with Mushroom ap It bgs Complete to Existing Surface Pad - _ - _ 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STAY: LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. H VANCE NOTICE REQUIRED /FOR �INSPECTIONS CONTRACTORS SIGNATURE TITLE G'� / DATE/ . Application Accepted By - Destruction Inspection By COMMENTS i )Y I/ILI ( { 3 - j ... jam..... -j.-... PARTMENT USE /O/ LY / - ----- Date_!1- — V - ate _ 11- 1__-, ZITV-- Area L�fq Employee ID# r4) '?W. mn c fl Rf _V LIF Y PE Sc Received1 Amount Permit/ J Codes Info By Cash emitted Date # Invoice # Well ID# —tel �Service -Request EHD 43-08 _tb t a �`�"� �t�[> A t!��'Yl t .� LL DESTRUCTION PERMIT 4/30/12 �N/� T